Safe Prescribing

Prescribing errors contribute to one of the most common adverse events in health care.

The factors contributing to prescribing errors are extremely complex and include:

1. Characteristics of the clinical environment,
2. Prescribing culture,
3. Workload, time, and support.

Prescribing is not about the isolated pharmacology but it requires contextualization with a patient.

Preventing Adverse Drug Reactions (ADR) 

Safe and rational prescribing and dispensing of drugs entails therapeutic reasoning and decision making, such as choosing the right drug for each individual patient. The occurrence of an ADR to previous treatment, as well as the individual patient’s risk factors should influence this choice. 

Considering the circumstances that may influence the occurrence of ADRs in a patient is the first and foremost essential step.  This implies developing knowledge of general risk factors such as:

• increased incidence of ADRs in the elderly,
• individual risk factors related to a certain drug or to a person’s medical condition, such as comorbidity and genetic factors,
• Drug–drug interactions can be expected, when patients use concomitant medication, especially in polypharmacy,
• Patients using herbal or other traditional medicines,
• Food–drug interactions may influence drug absorption or drug metabolism; for example, grapefruit juice inhibits drugs metabolized by cytochrome P450 (CYP)-3A4 

Information on these risk factors is generally available in drug labelling, treatment guidelines and medical literature, which you must learn to use and interpret.

When asking patient about specific features of a drug reaction you have to include any known drug allergy for the patient, and if the patient has any previous history of drug allergy it is vital that you must obtain more details about this allergy including:

• drug name; 
• character; 
• time-frame;
• possible non-drug causes (eg the illness itself);
• reactions to similar drugs;
• any prior skin/allergy testing  

These questions may help to delineate allergic vs non-allergic and serious vs non-serious reactions.

Tully et. al. grouped causes medication error into active failures, error-provoking conditions, and latent conditions, demonstrating the myriad of interacting factors involved in the complexity of prescribing within the context of a patient and the clinical environment.

Prescribing is not about the final prescription but the underlying process.

The written or oral prescription of a therapy is where an error manifests itself in a detectable way; however, it is well acknowledged that the complex process of prescribing is, in fact, a high-risk activity within which there are numerous opportunities for inaccuracies and mistakes.

The underlying process of generating the prescription includes a thorough background of pharmacological and therapeutic knowledge and skill; the ability to understand and assess the evidence base, cost effectiveness, and harm– benefit argument; and the facilitative communication skills to discuss management plans for therapy, monitoring, and dosage adjustment with other health care professionals and the patient[2].

The WHO six-step model has been designed as a normative model for therapeutic reasoning and prescribing and is suggested to provide a robust six-step guide to the process of rational and safe prescribing.

A systematic approach advocated by the World Health Organization can help minimize poor-quality and erroneous prescribing. This six-step approach to prescribing suggests that the physician should:

1. Evaluate and clearly define the patient's problem
2. Specify the therapeutic objective
3. Select the appropriate drug therapy
4. Initiate therapy with appropriate details and consider non-pharmacologic therapies
5. Give information, instructions, and warning
6. Evaluate therapy regularly (e.g., monitor treatment results, consider discontinuation of the drug).

The competency framework illustrated developed by the Royal Pharmaceutical Society provides the elements on what good prescribing looks like. For further reading refer to https://www.rpharms.com/resources/frameworks/prescribers-competency-framework

Prescribing is not only about personal knowledge, skill, and attitude but it is a participative process.

Error disclosure, analysis, and learning have to be recognized as ways to prevent error. Patient safety has to be adopted as a shared responsibility of all members of the team, with team work supported via interpersonal communication, collaboration, coordination, seeking qualified assistance when needed, and accepting colleague supervision, knowledge, and expertise. The interactive role of medical, pharmacy, and nursing staff has been demonstrated to enhance safe and effective use of medicines.

[1] Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V. The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(10):819–836.

[2] Aronson JK, Henderson G, Webb DJ, Rawlins MD. A prescription for better prescribing. Br J Clin Pharmacol. 2006;333(7566):459–460